Provider Demographics
NPI:1720768369
Name:AVILA, CYNTHIA GUADALUPE
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:GUADALUPE
Last Name:AVILA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8401 JACKSON RD
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95826-3904
Mailing Address - Country:US
Mailing Address - Phone:916-453-1482
Mailing Address - Fax:
Practice Address - Street 1:430 N PILGRIM ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95205-4428
Practice Address - Country:US
Practice Address - Phone:209-395-3561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-19
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist